A radiologist disagrees with the breast cancer screening guidelines

As a veteran of World War II, my grandfather was a GI Bill success story, the first man to go to college from his impoverished neighborhood in Jersey City thanks to government at its finest. A card-carrying member of the state teachers’ union, and a politically active Democrat for most of his life, it came as something of a shock to me when, after a few decades of observing big government debacles, my grandfather became one of Ronald Reagan’s most ardent fans. I still remember his delight over the classic Reaganism, “The nine most terrifying words in the English language are, ‘I’m from the government, and I’m here to help.’” To paraphrase the Gipper, Here we go again.

The United States Preventive Services Task Force (USPSTF), a panel appointed during the George W. Bush Administration and supported by the federal Agency for Healthcare Research and Quality, a branch of the U.S. Department of Health and Human Services, issued recommendations regarding breast cancer screening in 2009. This panel consisted of physicians in primary care (internists, pediatricians, Ob/Gyns), nurses, epidemiologists, biostatisticians, and public policy officials. Not one single breast cancer expert (breast surgeon, oncologist, radiologist, radiation oncologist) was included at the table, and there was neither invitation nor opportunity for breast cancer experts to address the panel before the recommendations were handed down. The panel recommended screening mammograms every other year, beginning at age 50; this was a significant departure from the 2002 USPSTF recommendations, which called for annual screening commencing at age 40. Incredibly, the panel also recommended that women should not be taught or encouraged to do breast self-examination, and that physicians should not perform clinical breast exams on their patients to check for cancer. Instead of being applauded as one of the few interventions in the healthcare system that actually saves people, with a 30% reduction in breast cancer mortality in the U.S. since 1991, breast cancer screening was under attack.

To support its proclamations, the panel used a computer model to create new, non-peer-reviewed data extrapolated from previously published studies on mammography screening. (At least Colin Powell wasn’t tapped to bring in the poster boards this time. The man is still my hero, despite all of that.) Some of these papers were decades old. The USPSTF used the lowest estimate of mortality reduction attributed to mammography (15%) among the various numbers that exist in the literature (as high as 54%). Even with their selective use of a low mortality reduction figure to create their new numbers, the USPSTF’s own “data” confirmed that significantly more women would survive if mammography screening began at age 40. But they ignored their own data, and they claimed that the supposed “harms” of screening (discomfort, anxiety, being called back for additional pictures, potentially having a needle biopsy that turns out to be benign, the risk of diagnosing cancers that wouldn’t necessarily kill the woman— though no one can tell us which cancers those are at the current time) outweigh the benefit of lives being saved. This was clearly not an objective, impartial scientific judgment; this was a value judgment, made with the over-arching goal of creating cost-saving public-policy recommendations for a broken healthcare system.

In practice, we are beginning to see the fallout from that judgment. The infamous “death panels” have already landed, folks. But contrary to expectations, it’s not grandma’s plug that’s being pulled; it’s women in their 40’s who are being hung out to dry.

The yellow circle in the mammogram image below denotes a 0.7cm invasive ductal carcinoma in a woman in her 40’s who decided not to follow the USPSTF guidelines, and to continue annual screening. This patient’s cancer was detected at stage I, with an estimated 5-year survival rate of 95%, an excellent prognosis. Her treatment consisted of a lumpectomy (breast conserving surgery) and radiation therapy. Chemotherapy was not required:

The mammogram image below is from a woman in her 40’s who had not yet had a baseline mammogram, and decided to put off screening until she turned 50 after she’d heard the USPSTF recommendations. One day she felt a lump in her breast, and her doctor sent her for a diagnostic mammogram. The yellow arrow in the image points to a 2.7cm invasive ductal carcinoma, at the site of her palpable lump. Unfortunately, this patient’s cancer had metastasized by the time it was diagnosed; her cancer is stage IV, with an estimated 5-year survival of 20%. Because her tumor is large compared to the size of her breast, a modified radical mastectomy (full breast removal) was recommended; the patient will also require many rounds of chemotherapy, and the best she can hope for is remission:

It has been estimated that if the USPSTF recommendations are followed as clinical guidelines, 20% of breast cancer deaths will occur in women who could have been saved. We have excellent data on mortality reduction as a result of screening women in their 40’s from numerous sources, including Dr. Laszlo Tabar’s group, Dr. Hendrick and Helvie’s study, and research presented from the Elizabeth Wende Breast Center in November 2011, to support the assertion that the USPSTF guidelines should be revised. In addition, this month’s edition of the journal Radiology published important original research concluding that mammography screening for 40- to 49-year-old women significantly decreases mortality.

The authors of this most recent study also found that cancers in women in their 40’s that were detected by mammograms required less invasive surgery (more lumpectomies rather than mastectomies; less lymph nodes removed), and these patients needed chemotherapy less frequently. These considerations were not even given a passing nod or mention by the USPSTF. These important additional benefits for women in their 40’s, when many people’s lives are impacted if these women become sick, include:

Higher likelihood of being a candidate for breast-conserving surgery, with a better cosmetic outcome. Don’t let anyone shame you into thinking that you are shallow and vain if you believe this is an important consideration.

Less likely need for chemotherapy—i.e. no hair loss, vomiting, fatigue, premature menopause, and a myriad of other side effects both temporary and permanent; less time missed from work and family obligations; less psychological trauma for yourself, your spouse and your children; less career disruption and the potential for discrimination due to your illness.

Less expensive treatment. In a world where even patients with “good insurance” end up spending a great deal of their own money out-of-pocket when they have cancer, sometimes putting themselves and their families into debt to cover the costs, this consideration matters a great deal. Estimated cost to treat early stage breast cancer: $14,000. Estimated cost to treat advanced breast cancer: $140,000.

Less likely need for complete removal of lymph nodes under the arm (axillary dissection), avoiding the potential lifelong misery of a chronically swollen and painful arm (lymphedema).

Any useful discussion regarding the value of screening for breast cancer must consider morbidity as well as mortality. It is severely unfair to women if these factors are left out of the debate, as they invariably have been until now.

I am not suggesting that screening mammography, even when started annually at age 40, is a panacea. If a woman has dense breast tissue, as half of women under 50 and 1/3 over 50 do, mammography is limited in sensitivity, many early cancers will not be seen on the mammogram, and a woman needs to discuss with her physician the possible need for an additional test in order to be effectively screened. Even for women who do not have dense breasts, mammography can be imperfect, which is why self-examination and clinical breast exam by your doctor are so important. In addition, women at high risk for breast cancer should develop an individualized, proactive screening plan with their doctor in order to protect themselves.

Breast cancer is the single most common cause of death in women age 35 to 50. If there’s any time to screen for it, it’s then. Don’t take one for the team on this. Cost savings for the system should not be attained by sacrificing women in our 40’s. An enlightened government should refrain from messing with what works, and should support efforts to make screening for breast cancer even more effective.

Disturbing. While the debate rages on, patients and primary care physicians are undoubtedly confused. The real question in my mind is… which guidelines do the insurance companies follow? My guess is that the average woman who discusses mammography with her physician is going to make a decision based on whether the mammogram will be covered by her insurance plan. Which guidelines do the insurers follow? If I understand correctly, The American Cancer Society strongly recommends that women begin screening mammography at age 40… which is a whole 10 YEARS earlier than the USPSTF recommended? If breast cancer is the leading cause of death in women age 35 to 50, why wait until 50 to begin screening??

Anonymous

I agree,it is disturbing. In my experience to date, if a woman’s doctor sends her for mammograms in her 40’s, insurers are covering. My concern is that many physicians are following the guidelines without understanding how flawed they are, and they are not sending 40-50 year old women for mammograms, not teaching them self-examination, and perhaps not even performing physical breast exams. You’re right, the American Cancer Society disagrees strongly with the USPSTF, and recommends screening annually at 40. Thanks for commenting, Victoria!

There is no excuse for not teaching breast self exam and encouraging women to learn and use the technique. It is inexpensive and easy to learn and gives patients the chance to learn how their breasts feel at different points in their menstrual cycle. They detect changes early and bring them to their physicians attention early if something appears. Dense breasts or no dense breasts the author is correct in stressing that routine mammography beginning at age 40 and annually finds earlier lesions and saves lives. Yes it leads to follow up studies that are costly, invasive and anxiety provoking. When the lesion turns out to be benign we all sigh with a sense of relief and move on. My dear wife has had two biopsies one of which removed a non malignant tumor that left her unable to breast feed our third child. She is eternally grateful for the lesions being benign and for the professional work of her surgeons and care teams. She has never argued that she had unnecessary disfiguring breast surgery for a non cancerous lesion. My first patient on my first day as a medical intern was a 28 year old woman with metastatic breast cancer being transferred to the hospice service for palliative care. I will never ever forget the discussion with her grief stricken husband and parents.I will continue to suggest to my patients that they learn and perform breast self examination and have their mammograms beginning at age 40

Anonymous

Self breast exam and physical exam are so important, especially for women too young to be screened with mammography. Many women find their own cancers, in a very low-tech, low-cost way. Thanks for your comments!

Curious… I’m a 40 year old breastfeeding mother, with large, fibrocystic breasts. Mammography seems like it would be of limited sensitivity for me, what are the other options?

Anonymous

Talk to your gynecologist, who can advise you based on your history and any risk factors. Many doctors advise delaying screening until a few months after ceasing breastfeeding. Of course, if you feel a lump or have another symptom, you need to be examined right away.

This is what happens when you depend on a third party payer system. The patient is no longer a human being, but is part of a computer model. We as patients must take responsibility for our health and wellness. Dr.’s must take a patient first stance. Thank you Dr. Vitiello for your article. As a man who loves his wife of 38 years this kind of article is as important to me as to my wife.

Anonymous

Thank you, Andy! You have a lucky wife.

Anonymous

It is hardly surprising that a radiologist is in favor of radioligical testing. Mammography is a multi-billion dollar industry and a decrease in mammograms means a decrease in income for radiologists…

Anonymous

Thanks for bringing this issue up. Healthy skepticism and informed decision-making are certainly important skills when you are a patient/consumer in today’s complicated healthcare system, full of competing agendas. It would be naive to think that charlatan doctors, who make recommendations to better serve their own pockets, don’t exist. However, protecting oneself from those concerns must be balanced with the acknowledgement that there are at least a few of us out there who are trying to get life-saving information to a wider group than our own families, friends, and patients. Because we see the suffering this disease causes when it’s not caught early, and because we think women aren’t being given the information they need in order to effectively protect themselves. I’m asking women to look at the information, and then decide for themselves.
The American Cancer Society and the American College of Ob/Gyns continue to strongly recommend screening mammograms annually starting at 40. It’s not just radiologists and surgeons who are taking this stance.

An accurate and honest information would have
1. presented the benefits of mammograms in absolute risk reduction by age group numbers not meaningless relative risk reduction or maybe as “out of 1000 women in their 40s…”.

2. Mentioned the cumulative risk of at least one false positive and at least one biopsy within 10 years of screening.

3. Mentioned overdiagnosis and its implications such as having surgery, likely radiation, maybe other treatments for leisions that would’ve never spread if remained undetected.

4. Mentioned that “cancer was detected early” is not the same as “life saved” because some cancers still kill no matter how early they are detected; some cancers don’t spread or spread so slowly that they are still localized in the breast when detected later. Yes, in some cases you manage to catch a cancer that is destined to spread during the time it would’ve been detected with mammograms and when it becomes noticeable, but these aren’t the majority. This is what epidemiologists are for – to look at the studies and determine how large the last group of cancers for which mammograms help is.

If you had been honest, if you didn’t have a paternalistic “I know better” attitude, you’d have presented the complete picture. But you failed to do it. This doesn’t speak well of your honesty.

Anonymous

You hit that nail on the head! In addition to the false positives and over-diagnosis, one has to consider the numbers needed to treat and the cumulative effects of radiation. As I recall, the NNT is quite high (I believe it was 100 women have to be screened to find one cancer). Relative to radiation exposure, the NY Times ran a series or articles last year on badly calibrated radiology equipment. Machines were administering much greater dosages than recommended. It was rather horrifying and I then started wondering how often (and if) all of the radiological devices are inspected for proper levels of radiation….

Anonymous

You’ve made me rethink the annual mammogram (again) – thanks for the information. Just wondering…the mammogram is imaging done with the hope of detecting cancer early when it is easier to treat, before it has spread. Why is it only the breast that this is applied to? Along those same lines -why not image other organs every year or two so things can be caught earlier when they are easier to treat. And why aren’t women under the age of 40 given ultrasounds/mammograms of their breasts? They get breast cancer too.

I strongly recommend reading book by H Gilbert Welch “Should I be tested for cancer”. The author is a well-respected doctor and researcher with many papers published in peer-reviewed medical journals. He is also a professor at Dartmouth Medical School.
The book doesn’t argue for- or against- screening, but it explains both benefits and risks of screening – yes there are risks – as well as why earlier isn’t always better. He also explains some very important concepts such as lead-time bias, length bias, overdiagnosis that are really important in understanding and in a way that is easy to read and understand. It may answer your questions about different forms of screening and why early detection doesn’t work for all cancers.
As to younger women – 1) their tissue is too dense to find much 2) their dense breasts are more susceptible to radiation risk 3) their risk of cancer is low, but the risk of screening is high.

You can also google for article “A Manifesto for Truth-in-Mammography Advertising” that a radiology professor wrote for his fellow radiologists calling them to give us about mammograms. While his motivation was malpractice, I think you’ll find the section called “The Knowledge Gap” quite interesting.

Interesting how you completely failed to mention the downside of mammography – like false positives and more importantly overdiagnosis. You also used meaningless statistics such as relative risk reduction instead of absolute risk numbers, you used reduction of breast cancer mortality which is affected by overdiagnosis. You also relied on anecdotes and emotions like this lady you mentioned — you cannot say for sure that her particular cancer would’ve been detected by a mammogram before it spread; statistically it’s more likely than it would not have.

You mention how radiologists and oncologists weren’t the part of the USPSTF commission. Why should they be? Their job is not to EVALUATE DATA from studies, their job is treating patiets. Yes, they have a lot of ANECDOTAL information, but evaluating studies is the job of epidemiologists. Oncologists or radiologists don’t have any more information about the studies that epidemiologists do, nor do they have any special knowledge of statistics. Their opinion is also biased.

Regarding “Higher likelihood of being a candidate for breast-conserving surgery,less likely need for chemotherapy, Less expensive treatment, Less likely need for complete removal of lymph nodes …” is offset by the overdiagnosis, by the fact that MORE screened women than un-screened get diagnosed with cancer to begin with.

Your “less likely” data didn’t look at the POPULATION numbers, it looked at the numbers of women diagnosed with cancer. Because of the overdiagnosis these numbers are meaningless. There are MORE mastectomies in screened group than unscreened – this is what studies showed.

Have you read by the way an article from your fellow radiologist (and radiology professor) “Manifesto for the truth-in-mammography advertising” – please look it up. I guess radiologists ignored his message and keep lying to patients.

Anonymous

This issue is so confusing for the patient. It is actually more helpful to make the case for annual mammography by simply sticking to the numbers. The problem with bringing up anecdotal stuff like showing that poor woman’s x-ray is that it clouds the issue by stirring up people’s emotions. You can just as easily show a sonogram of a cancerous ovarian tumor that has spread to argue for annual transvaginal ultrasounds and say that if it had been diagnosed earlier, the woman may have been cured. I had a neighbor who died of ovarian CA at the age of 34 leaving a young son behind. Maybe an annual sonogram would have saved her life.

I think the physicians on the task force came to their conclusions with the best intentions in mind – looking strictly at the evidence. They never said that annual mammography doesn’t save lives – they just weighed the risks versus the benefits – just like the rest of us do every time we get behind the wheel of a car. Who knows if their conclusion is spot-on – there are too many unknowns. Annual mammography saves lives but perhaps the patient should also be informed about its limitations when it is recommended. It may have been a bit oversold to the public.